Communication, teamwork, team-coordination – all buzzwords of patient safety and improved healthcare system performance. But does everyone truly know the meaning of these terms? We were presented a case study today in which an experienced and revered surgeon encouraged his surgical team to break protocol by closing a patient when the sponge count was off by one sponge. The surgeon cited, with amiability, the length of time under anesthesia as the urgency for ending the procedure before the missing sponge was accounted for – and rightly so, as longer times under anesthesia are associated with decreased patient outcomes. However, so are surgical materials left in patients. The concerned team deferred to the surgeon’s congenial and persistent request for the sutures to close the patient.
At first glance, this team could be considered to have some of the above qualities: they communicated about the missing sponge, they coordinated a course of action, and they did so in a seemingly patient and kind manner. However, my view is that the surgeon manipulated the team using his knowledge of their reverence and his kindness as a tool to encourage the response he desired. Not intentionally to harm the patient. Certainly he was acting in what he thought was the best interest of the patient as the decision-maker for that patient’s care. Sometimes, being too close to your team, in the absence of a structured communication method, can be dangerous.
The issue is, even if there had not been a sponge left in the patient, this is still a critical breakdown in communication and teamwork. The team leader encouraged the team to break hospital safety protocol and the team followed along. No one persisted to communicate the problem. The team did not come together to solve the issue, instead they relied on one person’s decision. Healthcare providers can tend to have an optimism bias when it comes to serious safety events – they typically do not believe that bad things are going to happen to them. And surgeons especially require a certain level of confidence to perform their jobs. The problem is, bad things, like accidentally leaving a surgical sponge in a patient do happen. All the time. And the protocols are there to protect against this. Encouraging the team to break protocol endangers the patient as well as the whole team. Although this event was multifaceted and would require a thorough evaluation (and full disclosure of harm to the patient and/or the patient’s family), two system-based improvements could help:
- There is a need for communication standardization and training so that nurses feel that they can persist against the wishes of the physician, have the training to do so, and the physicians have the training to accept feedback from the nurses they work with.
- As discussed throughout the past couple of days, there is an overall need for error reporting transparency within hospitals (at least) and ideally across hospitals so that healthcare providers can gain an awareness of the frequency and severity of serious safety events to reduce the optimism bias.
We traveled to Arlington cemetery today, a place I have been more times than I can count – it is always a requested tour of visitors to my Washington DC home. Today I saw this space in a new light. Four hundred thousand was the number. Four hundred thousand graves of soldiers who have given their lives in the name of country and freedom. We could see many of them from our perch on top of the hill. Four hundred thousand grave stones spanned the space below where we stood; and today that represented both the soldiers that gave their lives and the approximately four hundred thousand people who have died due to preventable medical error. Errors like the one described above that many healthcare providers do not think can happen to them.